10080224CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19648 STEVENS CREEK BLVD
CONTF.ACTOR: SUCCESS GRAPHIC SIGNS
PERMIT NO: 10080224
OWNER'S NAME: KCR DEVELOPMENT
1744 QUEENS CROSSING DR
DATE ISSUED: 08/31/2010
OWNER'S PHONE: 4088637346
SAN JC SE, CA 95132
PHONE NO: (408) 667-1777
LICENSED CONTRACTOR'S DECLARATION
r r r
BUILD ING
r, i ��
C
License Class �f' �
PERMIT INFO: BLDG ELECT PLUMB
Lic. #
MECH r RESIDENTIAL r COMMERCIAL r
Contractor s Date 71 I l�
1 hereby affirm that I am licensed under the provisions of apter 9
JOB D ESCRIPTION: ONE POT RESTAURANT - INSTALL ONE (1) SET
(commencing with Section 7000) of Division 3 of the Business & Professions
INTERNALLY ILLIMINATED INDIVIDUAL REVERSE CHANNEL
Code and that my license is in full force and effect.
LETTERS
hereby affirm under penalty of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area:
Valuation: $1500
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APPLICANT CERTIFICATION
APN Nt mber: 36906009.19648
Occupancy Type:
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit`jAddkiona0y, the applicant understands and will comply
18r) DAYS FROM LAST CALLED INSPECTION.
with all non-poin urce regulations he Cupertino Municipal Code, Section
9.18.
Signature Date
I 3 Date: !h 3 t`a)
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
1 oy affirm that I am exempt from the Contractor's License Law for one of
All roof., shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1, as owner of the property, or my employees with wages as their sole compensation,
inspectir n.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
Signatur: of Applicant: Date:
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business &Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations:
1 have and will maintain a Certificate of Consent to self -insure for Worker's
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
1 have r -ad the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
Califon is Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
complia rice with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety C ode, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contami nants as defined by the Bay Area Air Quality Management District 1 will
1 certify that in the performance of the work for which this permit is issued, 1 shall
maintair a complian watlr•the•Copertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Health 1 Code, Sections 25505, 25533, and 25534.
Compensation laws of Califomia. If, after making this certificate of exemption, I
OwneC'r '
become subject to the Worker's Compensation provisions of the Labor Code, I must
ZUtho a e t:
forthwith comply with such provisions or this permit shall be deemed revoked.
011 I
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
1 certify that 1 have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance of work's
correct. l agree to comply with all city and county ordinances and state laws relating
for whic r this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender'; Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender'; Address
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
V '1 non -point source regulations per the Cupertino Municipal Code, Section
ARCHITECT'S DECLARATION
9.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19648 STEVENS CREEK BLVD I CONTRACTOR: SUCCESS GRAPHIC SIGNS I PERMIT NO: 10080224
OWNER'S NAME: KCR DEVELOPMENT 11744 QUEENS CROSSING DR I DATE ISSUED: 08/312010
OWNER'S PHONE: 4088637346 1 SAN JOSE, CA 95132 1 PHONE NO: (408)667-1777
❑
LICENSED CONTRACTOR'S DECLARATION
License Class l/J�Y �/ Lie. k
Contractor Date - /
1 herehy affirm that l am licensed under the provisions of aplcr 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
BUILDING PERMIT INFO: BLDG r ELECT ❑ PLUMB r
NIECH r RESIDENTIAL r COMMERCIAL C
JOB DESCRIPTION: ONE POT RESTAURANT- INSTALL ONE (I) SL'f
INTERNALLY ILLIMINATED INDIVIDUAL REVERSE CIIANNEL
LETTERS
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a cenificateofconsent to self-insum for Worker's
Compensation, as provided for by Section 3700 of the Libor Code, for the
performance of the work for which this pemtit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this Sq. Ft Floor Area:
permit is issued.
APPLICANT CERTIFICATION
I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned properly for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilitics,judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. II the applicant understands and will comply
with all non-poin urce rcgulmions p he Cupertino Municipal Code, Section
9.18.
Signature Date_
❑ OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offerml for sale (Sec.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sm.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this pennit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Cali fomia. If, after making this certificate of exemption, 1
become subject to the Worker's Compensation provisions of the Libor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes, (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may aceme against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Date
Valuation: 51500
APN Number: 36906009.19648 1 Occupancy Type:
PERMIT EXPI:RES`IF'el RX I�OT STARTED
NNAyIIIN,180MAYS OFLPE711 ISSUANCE OR
)•80 DAYSFROM LAST Cxb�lffI ED INSPECTION.
Dale: 5 7 /—!O
RE -ROOFS:
All mo@ shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(x) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined Mthe Bay Arca Air Quality Management District I will
maintain compliance-withYheEapertino Municipal Code, Chapter 9.12 and the
Ileallh& f rl C de, Sections 25505, 25533, and 25534./''f
Owner or
�s1a4e:V-
CONSTRUCTION LENDING AGENCY'
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed
CITY OF CUPERTINO
ISI FEE ESTIMATOR - BUILDING DIVISION
J&FADDRESS:
FEE ID
DATE:
':]EE I'ED BY:
blech. Permit Fee:
APN:
BP#:
'VALUATION:
$1,500
*PERM1TTYPE: Building Permit
PLA,VCHECK 7'IPE:
PRIMARY Sign n
USE:
TOTAL
FLOORAREA:
PENTAMATION 10EAP5
PERMITTYPE:
WORK
$253.00
SCOPE
0.0
SIGN TYPE
FEE ID
P1amh. Plan Check
QTY
blech. Permit Fee:
SIGN FEE
IES/GN Elec. Permit Fee: IEPERAHT
Wall Sign, Electric
iSIGNWELEC
Other Elec. Insp. 0.0 $42.00
1
plemh. hop. Fre:
$253
Permit Fee:
$253.00
Suppl. Insp. Feed Reg. O 0'I'
0.0
hrs
$0.00
PME Unit Fee:
$42.00
PME Permit Fee:
$42.00
Consnuction Tai
Sign Master Plan: O Yes 0 No
$0.00
Work Without Permit? O Yes E) No
$0.00
TOTA LS:
Travel Documentation Fee: ITRA VDOC
$253.00
Strove Motion Fee: 18SEISIVIC0
NOTE. These fees are based on the prefinunarr information available and are onh• an estimate. Contact the Dep( for addn 7 info.
FEE ITEMS (Fee Resohoion 09-05I Eff 71/10)
Mach. Plan Check
P1amh. Plan Check
# Branch Circuits 1 $42.00
blech. Permit Fee:
Phtmh. Permi/ Fecr
IES/GN Elec. Permit Fee: IEPERAHT
Orher hfech. Insp.
Other Plumb Insp.Li I
Other Elec. Insp. 0.0 $42.00
Heck fasp. Fee:
plemh. hop. Fre:
Flee. Insp. Fee:
NOTE. These fees are based on the prefinunarr information available and are onh• an estimate. Contact the Dep( for addn 7 info.
FEE ITEMS (Fee Resohoion 09-05I Eff 71/10)
FEE
QTY/FEE
MISC ITEMS
Plan Check 1•ee:
Suppl. PC Fee: O Reg. O OT
0.0
hrs
$0.00
Phimb./d/ech./Elec Plan Check:
Permit Fee:
$253.00
Suppl. Insp. Feed Reg. O 0'I'
0.0
hrs
$0.00
PME Unit Fee:
$42.00
PME Permit Fee:
$42.00
Consnuction Tai
Sign Master Plan: O Yes 0 No
$0.00
Work Without Permit? O Yes E) No
$0.00
Planning Fees:
Travel Documentation Fee: ITRA VDOC
$42.00
Strove Motion Fee: 18SEISIVIC0
$0.50
Select an Administrative Item
Blda Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$380.50
$0.001
TOTAL FEE:
$380.50
Revised: 8/17/2010
CUPERTINO
CONTRACTOR / SUBCONTRACTOR LIST
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
Fax: 408-777-3333
JOB ADDRESS: Lf S '�,�/liJ i RMIT# � 0491-7- Cl
6—
OWNER'S NAME: C Yz -DC./a( PHONE # � —
GENERAL CONTRACTOR: �cce�S pgpr� e S USINESS LICENSE #
ADDRESS: ICITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENI%RAL CONTRACTOR AND ALL SUBCONTRAC S HAVE OBTAINED A CITY OF UPEIZTINO
BUSINESS LICENSE. 1�
1 am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
Owner / Contractor Signature Date
SUBCONTRACTOR
BUSINESS NAME
BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring / Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Painting / Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner / Contractor Signature Date
qt
amo-
CUPERTINO
CITY OF CUPERTINO
SIGN
.. PERMIT APPLICATION FORM
APN #
Date:
c-3 ole oo9:ta�f �-R
�7--9/-( 0
Building Address:
Mailing Address (if different from building address):
Owner's Name:
Phone #:
-7 -
Contractor:
Phone # _
��cc�6� ��ccQ4iZ SGS.✓
Fax#:
Contractor License #:n
Cupertino Business License #:
b (gs\
Contact:
Phone #:
Fax #:
Building Permit Info:
Bldg [ Elect Monument ❑ Mounted on Building
Residential Commercial
Job Description:
S-7A,'I Ci) �C ist2�v/ktt� `s C i, Int �sy�
Valuation (cost of project): W
$'6—a
Project Size: Express Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable, include in plan set & the. sheet index.
Revised 07/06/09
F ..
'Certificate of Compliance (Sian Lighting)
• I certify that this Certificate of Compliance documentation is accurate and complete.
(Page t of 2) SLTG-1C
Project Name:
Phase of Construction
❑ New Construction ❑ Addition ❑ Alteration
<f:)AJ,7 T
function TypeNn
Outdoor Signs 1:1Indoor Signs
Project Address:
�Q a!'e�
Date:
t O
Compliance Method Used ❑ Maximum Allowed
/,;,,�
Phone:
Lighting Power ❑ Alternate Lighting Sources
Documentation Author's Declaration Statement
• I certify that this Certificate of Compliance documentation is accurate and complete.
Name
Signature
Company
Date
'Address
If applicable:
that complies with the applicable requirements of § 119.
CEA #
CEPE #
City/State/Zip
Phone:
Principal Lighting Designer's Declaration Statement
• I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the lighting
design.
• This Certificate of Compliance identifies the lighting features and performance specifications required for compliance with
Title 24. Pages I and 6 of the California Code of Regulations.
• The design features represented on this Certificate of Compliance are consistent with the information provided to document
this design on the other applicable compliance forms, worksheets, calculations, plans and specifications submitted to the
enforcement agency for approval with this building permit application.
. Name:
SwQVg
Signature
❑
'
Company:
Phone
�)t t
Address:
CROSSII p—
License
Ciiq/State/Zip:
QA--� � ?�
Date%T
O I ( V
Sign Mandatory Measures
Indicate location on building plans of Mandatory.Sign Measures Note Block:
Mandatory Sign Lighting Controls
Yes
No
I
§133(a)l. All signs with permanently connected lighting are controlled with an automatic time switch control
❑
that complies with the applicable requirements of § 119.
§133(a)2. All outdoor signs are controlled with a photo control or outdoor astronomical:time switch control.
❑
Exception to §133(x)2. Outdoor signs are in tunnels or large covered areas that require: illumihation during
❑
davlight hours.
§133(x)3. All outdoor signs are controlled with a dimmer that provides the ability tuautomift0.fly reduce
❑
'
sign power by a minimum of 65 percent during nighttime hours.
Exception I to §133(x)3. Signs are illuminated folNss than one hour per day during daylight hours.
I ❑
3
Exception 2 to §133(a)3. Outdoor sigare in tunnels or large covered areas that requii�e:illumination
❑
during davli ht hours. 2, Via, ��3
Exception 3 to §133(x)3. Only metal halide, hieli.pres re sodium, cold cathode, orLr%onaainps are used to
❑
illuminated signs or pans of signs. " „ fl r,
§133(x)4. An Electronic Message Center (EM C);havinet new connected lighting greater than
Powerload
o'
15 kW has a control installed is capable,of Aducine lighting power by a minimutn:d0 percent when
e�i
�,
N
N/A
4
receiving a demand response signal that is sent out t v theyl&al utility.
❑
❑
Exception to §133(x)4. The EMC is required l y a health oplife
safety statue, oMinafiee or regulation,
Y
N
N
including but not limited to exit signs and trafi signs. \.J
❑
❑
2008 Nonresidential Compliance Forms
August 2009
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